Basic Information
Provider Information | |||||||||
NPI: | 1306244249 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMMUNITY FIRST HEALTHCARE OF ILLINOIS, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COMMUNITY FIRST MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5645 W ADDISON ST | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606344403 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7732827000 | ||||||||
FaxNumber: | 7735275900 | ||||||||
Practice Location | |||||||||
Address1: | 5645 W ADDISON ST | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606344403 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7732827000 | ||||||||
FaxNumber: | 7735275900 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/09/2014 | ||||||||
LastUpdateDate: | 12/09/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GREEN | ||||||||
AuthorizedOfficialFirstName: | EDWARD | ||||||||
AuthorizedOfficialMiddleName: | JOSEPH | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/LEGAL COUNSEL | ||||||||
AuthorizedOfficialTelephone: | 3128324375 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | J.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 0001719 | IL | Y |   | Hospitals | General Acute Care Hospital |   |
No ID Information.